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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602987
Report Date: 04/11/2024
Date Signed: 04/11/2024 01:01:14 PM


Document Has Been Signed on 04/11/2024 01:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:HEIGHTS INN, THEFACILITY NUMBER:
198602987
ADMINISTRATOR:QUEZADA, JESSEFACILITY TYPE:
740
ADDRESS:2400 PANCHOY PLTELEPHONE:
(562) 488-3830
CITY:LA HABRA HEIGHTSSTATE: CAZIP CODE:
90631
CAPACITY:9CENSUS: 4DATE:
04/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Jesse Quezada TIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to caregiver Diana Gonzalez and the facility administrator Jesse Quezada arrived shortly after.

The following 12 (CARE) tool domains were utilized during the inspection:

Infection Control: Infection Control Practices and Personal Protective Equipment (PPE) supplies were observed. Facility Staff still practice hand washing and wear mask in the facility. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan was collected and reviewed during this visit.

Operational Requirement: The facility is licensed for (9) residents with age range 60 and over. 9 Non-ambulatory and hospice waiver for five (5). Currently, the facility has two (2) hospice waiver residents, One (1) with home health. The facility has a Dementia Care Plan in the Plan of Operation. A Hospice Waiver is approved for up to (5) residents. All residents in the facility are non-ambulatory. Facilities liability insurance was reviewed and copy collected.

Physical Plant and Environmental Safety: The facility is located in a residential neighborhood. The facility includes a staff office, laundry room, dining area, common area/TV room, staff bathroom, (6) residents bedrooms and (6) resident bathrooms and a detached garage.LPA inspected the bathrooms, each bathroom is clean, sanitary and in a good working condition. Each bathroom has the required grab bar and non-skid mat. The hot water in all resident bathroom are tested within the Title 22 regulation. All the cleaning supplies and chemicals are stored and locked inaccessible to residents. The extra linen and towels were observed. Carbon monoxide and Smoke detectors tested and operational. No bodies of water observed.

Staffing: The facility has sufficient staffing in the facility. The facility has at least one person to have updated First Aid and CPR training certificate.



Continued on LIC 809-C
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HEIGHTS INN, THE
FACILITY NUMBER: 198602987
VISIT DATE: 04/11/2024
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Personnel Records-Training Information: All the staff work in the facility are over 18 yeas old and background checked and associated with the facility. (4) Staff files were reviewed. Required documents observed. Administrator Certificate is current.

Resident's right/Information: Required posting were observed such as the complaint poster from LTCO and CCL ,as well as the resident personal right and theft and loss policy. The facility also has internet service available to residents in care.

Planned Activities: The facility has a sufficient space to accommodate both indoor and outdoor activities.

Food Service: The facility has sufficient food supply for two days perishable and seven days non-perishable food in the facility. Currently there's no resident is on a modified diet that prescribed by the doctor.

Incidental Medical and Dental: LPA reviewed four (4) Resident medications. The medication in the facility is centrally stored and locked inaccessible to residents in care. First aid kid and Manual observed.

Resident's Record-Incident Reports: A total of four (4) resident files were reviewed. Required documents were observed. There are no residents with dementia diagnosis

Disaster Preparedness: The updated Emergency and Disaster Plan LIC 610E is in place and posted on the wall. It is updated yearly. Emergency drills conducted quarterly.

Residents with Special Health Needs: Two (2) residents receive hospice care. Half and Full bed rails for mobility assistance were observed. (1) Resident receives Home Health Services. Hospice Care and Home Health Service Folders were observed and reviewed. No Residents have prohibited health condition.

Per California Code of Regulations, Title 22, no deficiencies are being cited today. (3) Residents had camera monitors in their rooms provided by families. LPA requested staff to remove cameras and provide the Department an exception request for each individual who wants to have a camera in their rooms. The department will review requests for each individual and provide an approval or refusal.

Exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
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